Download Provincial Medical Genetics Program

CEAN Clinic (Psychiatric genetic counseling)
Tel: (604) 875-2157
Fax: (604) 875-2825
Provincial Medical Genetics Program
B.C. Children’s Hospital
Room C234, 4500 Oak Street, Vancouver, BC, V6H 3N1
DATE OF REFERRAL: ________________________________
___________________________________________________
(PATIENT SURNAME, FIRST)
(PREVIOUS / MAIDEN NAME)
___________________________________________________
(ADDRESS)
________________
(DOB: YY/MM/DD)
______________
(HOME PHONE)
_____
___________________
(AGE)
(PHN)
______________
(WORK PHONE)
_____________
(CELL PHONE)
Reason for referral or psychiatric diagnosis:
Please list current medications: _________________________________________________________________________
Any family or relative seen in Medical Genetics?
□ NO □ YES: ______________________________________(name/DOB)
Does this patient need an interpreter?
□ NO □ YES: _______________________________________ (language)
Is this referral regarding a current pregnancy?
□ NO □ YES: _______________________________________(LMP date)
REFERRING DR:
FAMILY DR:
BILLING NO:
BILLING NO:
ADDRESS:
ADDRESS:
PHONE NUMBER:
PHONE NUMBER:
FAX NUMBER:
FAX NUMBER:
Please list any other doctors involved with patient’s care:
Please forward all relevant consults, reports and tests
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